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Surgical Unit-Based Safety Program

Proposed Resources for Partnership for Patients

Terri Conner, Ph.D.

Nybeck Analytics

Partnership for Patients

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HOSPITALIZATIONS ARE RISKY

In the U.S.– 7% of patients suffer a medication error– On average, every patient admitted to the ICU

suffers an adverse event– 44,000 – 98,000 people die in hospitals each year

as the result of medical errors– An additional 100,000 deaths from health-care

associated infections– Cost of HAI is $28-33 billion

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SURGERY IS RISKY

25% of in-patient surgeries are followed by a complication, many leading to:– Prolonged LOS– Re-admission– Death

50% of all hospital adverse events are linked to surgery– At least 50% of adverse surgical events are

preventable

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PROJECT GOALS

To achieve significant reductions in surgical site infection and surgical complication rates– Reducing complications reduces readmissions

To achieve significant improvements in safety culture

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IMPORTANT POINTS

Harm is preventable– Many HAIs and complications are preventable,

and should be viewed as defects

Technical and adaptive work– Focus on systems; not on individuals– Engage frontline staff to identify and fix local

opportunities to improve

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SUSPNot Just a Checklist Program

Informed by science– Medical best evidence– Social science

Led by clinicians and supported by management

Guided by measures

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SUSP INTERVENTIONS

No single SSI prevention bundle– Dive deeply into SCIP measures to identify local

defects– Emerging evidence

Bowel prep Antibiotic redosing Chlorhexidine skin prep

Capitalize on frontline wisdom to identify local opportunities to improve

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HOW WILL WE GET THERE?

SUSPTechnical component

– TRIP: Translating Evidence into Practice

Adaptive component– CUSP: Comprehensive Unit-based Safety

Program

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SUCCESSFUL EFFORTS

Michigan Keystone ICU program

– Reduction in central line-associated blood stream infections

– Reduction in ventilator-associated pneumonias

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TRIP: Translating Evidence Into Practice

Summarize the evidence

Identify local barriers to implementation

Measure performance

Ensure all patients get the evidence

– 4 E’s Model

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4 E’S MODEL TO HELP IMPLEMENT PATIENT SAFETY INTERVENTIONS

Engage– How does this make the world a better place?

Educate– What do we need to know?

Execute– What do we need to do?– What keeps me from doing it?– How can we do it with our resources and culture?

Evaluate– How do we know we improved safety?

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CUSP

Comprehensive Unit-based Safety Program

An intervention to learn from mistakes and improve safety culture

A good approach whenever there is a gap between evidence-based practice and current practice on your unit.

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CUSP: EMPHASIS ON CULTURE

Shared attitudes, values, goals, practices,

behaviors

Culture influences behavior

– Participation in quality improvement efforts

– Communication

Breakdown in communication contributes to nearly all adverse

events.

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CUSP: COMPREHENSIVE UNIT-BASED SAFETY PROGRAM

Safety practices part of daily work

Implemented at the unit level

Led by clinicians

Structured program, yet flexible

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PRE-CUSP STEPS

Assemble Safety Team

– Multidisciplinary

– Different levels of experience

– Encourage joining team at any phase of the program

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PRE-CUSP STEPS

Team Members – frontline staff– Project Leader (Unit Champion)– Nurse Manager– Physician Champion– Senior Hospital Executive– Patient Safety Coordinator– Epidemiology / Infection Control– Coach

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PRE-CUSP STEPS

Measure Safety Culture

– Before CUSP implementation, and then every 12-18 months

– Use AHRQ’s The Hospital Survey on Patient Safety Culture

(HSOPS)

– All clinical and non-clinical providers

– Report results to the unit and senior hospital executive

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CUSP STEPS

1. Science of safety training

2. Identify defects

3. Assign executive to adopt unit

4. Learn from defects

5. Implement teamwork tools

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STEP 1: SCIENCE OF SAFETY TRAINING

Goals

– Magnitude of patient safety problem

– Foundation for investigating safety defects

– Providers’ involvement significantly affects patient

safety

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STEP 1: SCIENCE OF SAFETY TRAINING

Learning Objectives

– Safety is a property of the system

– Use strategies to improve system performance

Standardize work

Create independent checks for key processes

Learn from mistakes

– Apply strategies to both technical work and team work

– Teams make wise decisions with diverse and independent input

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STEP 1: SCIENCE OF SAFETY TRAINING

Training Session– 3-part “Improving Safety” presentation by Dr. Peter Pronovost

Part 1: http://www.youtube.com/watch?v=GOJJHHm7lnM Part 2 - http://www.youtube.com/watch?v

=wpzb7nM6oFQ&feature=related Part 3 - http://www.youtube.com/watch?v=6BnXs4KtER8&feature=related

– Instruct staff on reporting of safety concerns

– Describe executive safety rounds

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STEP 2: IDENTIFY DEFECTS

Eyes and ears of patient safety

Ongoing process

Disseminate Staff Safety Assessment Form

Combine results and prioritize defects

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WHAT IS A DEFECT?

Anything you do not want to have happen again. Many HAIs are preventable. They should be viewed

as defects.

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STEP 2: IDENTIFY DEFECTS

Staff Safety Assessment Form

– Purpose: Tap into your knowledge and experiences at the

frontlines of patient care to find out what risks are present

on your unit that do or could jeopardize patient safety.

– All health care providers in the unit complete this form.

– 2-item questionnaire

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STEP 2: IDENTIFY DEFECTS

Staff Safety Assessment Form

1. Please describe how you think the next patient in

your unit/clinical area will be harmed.

2. Please describe what you think can be done to

prevent or minimize this harm.

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STEP 2: IDENTIFY DEFECTS

Combine Results

– Group into common types of defects

Communication

Medication process

Patient falls

Supplies

– Frequency distributions

Example: communication, 57%

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STEP 2: IDENTIFY DEFECTS

Prioritize safety concerns

– Obtain input from CUSP team senior executive

– Prioritize based on

Likelihood of causing patient harm

Severity of harm

How common is the problem

Likelihood it can be solved by implementing a daily work process

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STEP 4: LEARN FROM DEFECTS

Four Key Questions

1. What happened?

2. Why did it happen?

3. What will you do to reduce the chance it will recur?

4. How do you know that you reduced the risk that it will happen again?

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WHAT HAPPENED?

Reconstruct the timeline and explain what happened

Put yourself in the place of those involved, in the middle of the

event as it was unfolding

Try to understand what they were thinking and the reasoning

behind their actions/decisions

Try to view the world as they did when the event occurred

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WHY DID IT HAPPEN?SYSTEM FAILURES

Arise from managerial and organizational decisions that shape

working conditions

Often results from production pressures

Damaging consequences may not be evident until a “triggering

event” occurs

Develop lenses to see the system factors that lead to the event

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WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN?

Prioritize most important contributing factors

Prioritize most beneficial interventions

Safe design principles

– Standardize what we do

– Create independent check

– Make it visible

Safe design applies to technical and team work

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WHAT WILL YOU DO TO REDUCE THE RISK OF IT HAPPENING AGAIN?

Develop list of interventions

For each intervention:

– Rate how well the intervention solves the problem or

mitigates the contributing factors for the accident

– Rate the team belief that the intervention will be

implemented and executed as intended

Select top interventions (2 to 5) and develop intervention plan

– Assign person, task follow-up date

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HOW DO YOU KNOW RISKS WERE REDUCED?

Did you create a policy or procedure?

Do staff know about policy or procedure?

Are staff using the procedure as intended?

– Behavior observations, audits

Do staff believe risks were reduced?

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STEP 4: LEARN FROM DEFECTS

Summarize and Share Findings

– Learning from Defects Tool

Detailed form for each incident or identified defect

– Case Summary Form

Summarize the case

Identify system failures

Identify opportunities for improvement

List actions taken to prevent future harm

– Share your findings

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STEP 4: LEARNING FROM DEFECTS

Key Points

– Focus on systems, not people

– Prioritize

– Go mile deep and inch wide, rather than mile wise and inch

deep

– Pilot test

– Learn from 1 defect a quarter

– Answer the four questions

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STEP 5: TEAM WORK TOOLS

Staff Safety Assessment

Safety Issues Worksheet

Status of Safety Issues

Learning from Defects Tool

Case Summary Form

Briefings/Debriefings

SSI Investigation

Audits

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STAFF SAFETY ASSESSMENT

Used to identify defects in the unit

1.Please describe how you think the next patient in your

unit/clinical area will be harmed.

2.Please describe what you think can be done to

prevent or minimize this harm.

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SAFETY ISSUES WORKSHEET

Identified Issue Potential/Recommended Solution

Resources Needed

Resources Not Needed

1.

2.

3.

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STATUS OF SAFETY ISSUES

New and OngoingDate Safety Issue Contact Status Goal

                                                                                 

New and OngoingDate Safety Issue Contact Status Goal                                                                                 

CompletedDate Safety Issue Contact Status Goal                                                                                 

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LEARNING FROM DEFECTS

Explain what happened. Check off the factors that negatively or positively contributed to

the incident. Describe how you will reduce the likelihood of this defect

happening again by completing the tables. Develop interventions, and choose 2-5 to implement.

– What will be done?– Who will lead the intervention?– When is follow-up?

Describe how you know you have reduced the risk. Summarize your findings using the Case Summary Form.

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CASE SUMMARY FORM

Form SectionsSafety tips

Case summary

System failures

Opportunities for improvement

Actions taken to prevent harm

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BRIEFINGS / DEBRIEFINGS

Dominant tool for SUSP

Growing evidence–Better team performance–Better safety culture–Reduction in delays

Adapted to local hospital and OR

Adapted to surgery type

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SSI INVESTIGATION TOOL

Look into factors that may be systematically contributing to SSIs

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AUDITS

Skin prep audits

Antibiotic audits

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OTHER TOOLS

Mislabeled specimens

Wrong sided surgery

Retained foreign objects

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SUSP IS A CONTINUOUS JOURNEY!!